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Infectious Endophthalmitis
Symptoms ,Signs, Differential
Diagnosis
MR.Ansari MD
Infectious endophthalmitis is a condition in which the
internal structures of the eye are invaded by replicating
microorganisms .
Exogenous endophthalmitis occurs when the outer wall of
the eye sustains a break as a result of surgery or trauma.
Exogenous endophthalmitis is the most common subtype.
90% of all cases are caused by bacteria.
In certain clinical settings ,there is an increased likelihood of
infection by certain groups of bacteria .
Endophthalmits following cataract surgery is most often
caused by staphylococcus epidermidis.
Injured eyes → Gram-positive Bacillus spp.
Allen reviewed 30000 ICCE from 1964 to 1977 and found an
incidence of endophthalmitis of 0.057% .
Review of 23625 cases of ECCE in Bascom Palmer Eye Institute
revealed an incidence of 0.072%
Phaco →incidence of 0.03% to 0.04%
In Sweden & Norway →0.1% to 0.16%
Following open globe injuries→4.2% to 7% .
Symptoms of Acute Endophthalmitis
( within 6 weeks )
Sudden increase in pain 1-7 days after surgery .
↓VA
Redness and conjunctival injection.
Lid swelling
In EVS 98% with acute endophthalmitis presented with one
or more of the four classic symptoms.
↓VA ( 93% )
Conjunctival injection ( 81% )
Pain ( 75% )
Lid swelling ( 33% )
Signs of acute endophthalmitis
In fulminant cases conjunctival chemosis and increased injection
often with a significant amount of yellowish exudates in the
conjunctival cul - de - sac
Edematous lids often difficult to open
Corneal edema ( variable degrees )
Pigmented cells may accumulate on its posterior surface of
cornea.
Surgical wound may show signs of dehiscens and in advanced
cases exudates can stream from the wound.
AC reaction ( heavy flare and cells )
Hypopyon ( mixed with a tinge of red blood )
Fibrin membrane is usually present over both surfaces.
Heavy cellular debris is present in the vitreous .
Focal accumulations of whitish material or sheets of opacification
within the vitreous .
IOP → low , normal or high .
Pupil often dilates poorly .
Retinal prephlebitis has been reported an early sign but in most
cases the retinal vessels are seen poorly .
Red reflex ?
Notice to risk factors
Leakage of wound
Rupture of posterior capsule
Vitreous wick
Time of operation
Diabetes mellitus
Cutting of sutures too early
A case – control study demonstrated a threefold greater risk of
endophthalmitis with clear corneal incisions than with scleral
tunnel incisions .
Continuation
Temporal incisions were noted to have a higher incidence of
infection than superior incision .
Transcleral suture fixation of posterior – chamber IOL .
Polypropylene haptics
Preoperative eyelid abnormalities and blepharomeibomitis .
Re – entry of the eye through a previous wound .
Differential Diagnosis
Postoperative inflammation
Retained lens material →respond to corticosteroids.
Chronic , low grade endophthalmitis may occur secondary to
coagulase – negative Gram – positive organisms such as
s.epidermidis and also result from infections with the anaerobic
species Propionibacterium acnes . ( 40% of cases )
Propionibacterium can present with mild iritis and pigmented KP .
Continuation
On examination , the most common findings are vitritis , white
plaques on the posterior capsule or the IOL , beaded fibrin
strands , hypopyon ?,granulomatous KP .
TASS
Toxic substance enters the anterior chamber
Causes Acute sterile postoperative inflammation
Photophobia , ↓VA , corneal edema and marked anterior
chamber reaction with hypopyon
TASS presents within hours of surgery
Pathologic changes limited to AC
Pain is much less than that of endophthalmitis
↑IOP
Tainted BSS , reusable double cannula , se of preserved solution ,
subconjunctival injection near the wound .
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